This site is maintained for Midwives in Private Practice (MiPP), a collective of independent midwives in Victoria. We are committed to the essence of midwifery, being 'with woman' - each woman and her midwife preparing to welcome the child she bears, working in harmony with and protecting intuitive natural processes in birth and nurture of the newborn and the establishment of loving, resilient families.

Sunday, August 18, 2013

Maternity care plan

Midwives who are eligible to participate in Medicare, and offer Medicare rebates for women in their care, have this item in the Medicare schedule:

Item 82115

Professional attendance by a participating midwife, lasting at least 90 minutes, for assessment and preparation of a maternity care plan for a patient whose pregnancy has progressed beyond 20 weeks, if:

(a) the patient is not an admitted patient of a hospital; and

(b) the participating midwife undertakes a comprehensive assessment of the patient; and

(c) the participating midwife develops a written maternity care plan that contains:

(i) outcomes of the assessment; and

(ii) details of agreed expectations for care during pregnancy, labour and delivery; and

(iii) details of any health problems or care needs; and

(iv) details of collaborative arrangements that apply to the patient; and

(v) details of any medication taken by the patient during the pregnancy, and any additional medication that may be required by the patient; and

(vi) details of any referrals or requests for pathology services or diagnostic imaging services for the patient during the pregnancy, and any additional referrals or requests that may be required for the patient; and

(d) the maternity care plan is explained and agreed with the patient; and

(e) the fee does not include any amount for the management of labour and delivery
(Includes any antenatal attendance provided on the same occasion)
Payable only once for any pregnancy

It's clear from the legislation that a 'maternity care plan' is an important aspect of the antenatal care provided by a participating midwife. The professional attendance linked to Item 82115 is to take at least 90 minutes, and the scheduled fee is $319.00. This compares with other antenatal attendances of at least 40 minutes, with a scheduled fee of $53.40. Clearly, someone who advised the writer of this piece of legislation considered that the writing of a maternity care plan, and the other tasks (listed above) are very significant.

A midwife who has recently received her endorsement as an eligible midwife wrote to a social media site "I wonder
if anyone could share their written maternity care plan format? Just want to know what you include and how to set it out ..."

works in partnership with women to give the necessary support, care
and advice during pregnancy, labour and the postpartum period,

to
conduct births on the midwife’s own responsibility and

to provide care
for the newborn and the infant.

This care includes preventative
measures, the promotion of normal birth, the detection of complications
in mother and child, the accessing of medical care or other appropriate
assistance and the carrying out of emergency measures.
...

The insurance company MIGA, in consultation with ACM and APMA, has developed a care plan that some midwives have adopted. This care plan has a lot of boxes to tick, and much of the information would be collected routinely by midwives in taking a history and discussing care options with each woman. Those who are using specially designed software would have many of the points of this care plan covered in entering the client information, and would be able to generate a maternity care plan printout when required.

The maternity care plan is to be kept with other professional records for each woman and baby, by the midwife. The care plan usually does not need to be shared with anyone, unless asked for, for example, in a Medicare audit or an investigation.

There is ongoing discussion and concern about the relationship between midwives and public hospitals, particularly those hospitals that have, to date, refused to discuss any collaborative arrangements with midwives. MIGA states that, in order to meet the legislative requirements, a midwife is required to have:

A Collaborative Arrangement with a doctor or Hospital, or

A Care Plan communicated to a public Hospital providing obstetric services

You should ensure this is acknowledged by the Hospital either in writing or as a record in your notes of an oral acknowledgement

We note here that midwives in Melbourne, and many other places, who have attempted to comply with this requirement of acknowledgment (written or oral) by a hospital have had no success. The hospitals have, to date, not been interested in collaborating with midwives. Some hospitals have returned care plans to the midwife, and instructed her not to send them. This problem seems to be ongoing, as was discussed in a previous post on this blog.

The MIGA maternity care plan seems to attempt to cover the 'what if' situations, in which a midwife might be required to defend her or his actions. That makes sense - that's the job of insurance companies.

But, ...

Midwifery is not, primarily, about defensive practice. It's about the midwife acting in a way that protects the wellbeing and safety of mother and baby. It's about being 'with woman', in a special professional relationship. It's about health promotion: healthy mothers and babies. Midwives should not be instructed by an insurer, an entity that exists to make a profit for shareholders, as to the care plans they make.

Midwives are encouraged to make a positive statement in each woman's maternity care plan, such as:

"When providing primary maternity care for a well woman, the plan is to
proceed under normal physiological conditions, working in harmony with
the natural processes, unless complications arise. If illness or
complications are suspected, a transfer to the planned hospital would be
arranged without delay for urgent obstetric concerns, ..."

Midwives choosing to work privately, rather than being employed by hospitals, do so because it allows us to be flexible about the care we provide. We offer one-to-one primary care, which enables the woman and her midwife to establish a partnership based on trust and reciprocity.

Midwives who are interested in extending their practices to include a caseload and homebirth, whether as independent (self-employed) practitioners or as employees of a maternity service, are welcome to join in with MiPP activities. If you have a blog or website that you would like linked to this blog, or have other questions, please get in touch.

Thankyou for visiting this blog. I hope you will find it informative and useful. If you want to contact me by email, rather than leaving a message in the comments section of the blog, please do so joy@aitex.com.au.Joy Johnston